Case presentation: We report a case of a spontaneous ilio-iliac arteriovenous fistula in a 68-year-old Caucasian man detected following presentation with unilateral claudication and cong
Trang 1C A S E R E P O R T Open Access
Hybrid management of a spontaneous ilio-iliac arteriovenous fistula: a case report
Gavin C O ’Brien*
, Colm Murphy, Zenia Martin, Naseem Haider, Mary P Colgan, Dermot Moore, Prakash Madhavan and Sean M O ’Neill
Abstract
Introduction: Spontaneous iliac arteriovenous fistulae are a rare clinical entity Such localized fistulation is usually a result of penetrating traumatic or iatrogenic injury Clinical presentation can vary greatly but commonly includes back pain, high-output congestive cardiac failure and the presence of an abdominal bruit Diagnosis, therefore, is often incidental or delayed
Case presentation: We report a case of a spontaneous ilio-iliac arteriovenous fistula in a 68-year-old Caucasian man detected following presentation with unilateral claudication and congestive cardiac failure Following
computed tomography evaluation, the fistula was successfully treated with a combined endovascular (aorto-uni-iliac device) and open (femoro-femoral crossover) approach
Conclusion: Endovascular surgery has revolutionized the management of such fistulae and we report an
interesting case of a high-output iliac arteriovenous fistulae successfully treated with a hybrid vascular approach
Introduction
Spontaneous iliac arteriovenous fistulae (AVF) are a rare
clinical entity Such localized fistulation is usually a
result of penetrating traumatic or iatrogenic injury [1]
Clinical presentation can vary greatly but commonly
includes back pain, high-output congestive cardiac
fail-ure (CCF) and the presence of an abdominal bruit
Diagnosis, therefore, is often incidental or delayed [2]
Case presentation
A 68-year-old Caucasian man was referred to our
out-patients clinic following the incidental discovery of a 6
× 8 cm distended iliac vessel whilst having an
ultra-sound for surveillance of liver cirrhosis His clinical
his-tory revealed a progressive hishis-tory of right flank pain,
worsening right leg claudication and a persistently cold
sensation in his right foot He also complained of
pro-gressive breathlessness on exertion, clinically suggestive
of deteriorating CCF There was no history of trauma or
previous surgery Ankle-brachial pressure measurements
revealed a reduced index of 0.76 on the right, and a
nor-mal index of 1.35 on the left with corresponding toe
pressures of 55 mmHg and 143 mmHg respectively A contrast enhanced computed tomography (CT) scan showed an isolated right common iliac artery (CIA) to right common iliac vein AVF (Figure 1) His aorta was normal in caliber, measuring 19 mm at the aortic bifur-cation The aneurysmal segment began immediately dis-tal to the aortic bifurcation at the origin of the right CIA, with no normal segment of CIA evident The aneurysm measured 9.4 cm in maximal diameter and extended to within 17 mm of the right iliac bifurcation
It was impossible to differentiate the arterial wall from the venous wall in the aneurysmal segment on either ultrasound or CT scans His inferior vena cava (IVC) was grossly distended with a uniform diameter of 36
mm in its full course
Pre-operative discussions focused on finding an endo-vascular strategy to solve the problem As no normal caliber proximal right CIA existed, an isolated iliac cov-ered stent was impossible as no proximal sealing zone existed This required sealing a proximal stent in his aorta Bifurcated endografts have been used to seal ilio-iliac fistulae previously [1] The aortic bifurcation dia-meter was 19 mm in this case and although some devices have reported success negotiating smaller aortic bifurcations [2], we felt an aorto-bi-iliac graft would be
* Correspondence: gavinobrien@rcsi.ie
St James ’ Hospital Vascular Department, St James’ Hospital, Dublin 6, Ireland
© 2011 O ’Brien et al; licensee BioMed Central Ltd This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
Trang 2in danger of being compressed at the bifurcation with a
high risk of occlusion As a result, a hybrid approach
with deployment of an aorto-uni-iliac (AUI) device
fol-lowed by a femoro-femoral bypass was planned Our
patient was operated upon in our endovascular suite
(Siemens) under spinal anesthesia Both common
femoral arteries (CFA) were controlled and cannulated
with 6Fr sheaths (Johnston & Johnston) His aorta was
cannulated with a 0.035 wire Bentson wire (Cook
Medi-cal, Bloomington, IN, USA) via each CFA with the
assis-tance of an angled catheter (Kumpe, Cook Medical) A
diagnostic flush pigtail catheter was placed in his aorta
via the contralateral limb A stiff 0.035 Amplatz wire
(Amplatz Super Stiff, Boston Scientific) was exchanged
as access to the ipsilateral limb Following an angiogram
to confirm renal anatomy, an aorto-uni-iliac device
(Zenith Renu, Cook Medical) was deployed from
imme-diately below his renal arteries to his mid right external
iliac artery, thus occluding his right internal iliac artery
A 14 × 10 mm Amplatzer occlusion device (AGA
Medi-cal Corp, MN, USA) was deployed via the contralateral
limb to his proximal left CIA A completion angiogram
confirmed exclusion of the ilio-iliac AVF A right to left
femoro-femoral bypass with 8 mm
polytetrafluoroethy-lene (PTFE) was performed to re-establish flow to his
left leg as well as providing left internal iliac perfusion
On the first postoperative day, the mass was no longer
pulsatile and the machinery-like murmur in the right
iliac fossa was absent A CT scan on postoperative day
two confirmed a patent AUI endovascular graft and
patent femoro-femoral bypass, as well as confirming exclusion of contrast from the right iliocaval system (Figure 2) His right foot no longer felt cool and the postoperative ankle brachial index (ABI) confirmed an index of 1.05 on the right and 0.95 on the left, with cor-responding toe pressures of 119 mmHg and 117 mmHg respectively He was discharged after seven days without complication At a clinic one month later, his claudica-tion had resolved completely and he no longer had symptoms suggestive of CCF A duplex ultrasound con-firmed exclusion of arterial flow from the iliocaval vessels
Discussion
Penetrating traumatic injury remains the most common cause of abdominal and pelvic arteriovenous fistulae [3] This trauma may be malicious but is frequently iatro-genic, commonly occurring after lumbosacral laminect-omy whereupon penetration of the anterior longitudinal
Figure 1 Preoperative CT Preoperative contrast-enhanced CT 3-D
reconstruction with arrow demonstrating the 8 cm ilio-iliac AV
fistula originating from the proximal right CIA.
Figure 2 Postoperative CT Postoperative CT 3-D reconstruction showing endovascular exclusion of the AV fistula with an aorto-uni-iliac graft (white arrow) and a functioning right to left femoro-femoral cross-over bypass (red arrow).
Trang 3ligament by dissecting instruments can injure the aorta,
IVC or iliac vessels, depending on the level of the
lami-nectomy [4] Linton and White first reported such a
case in 1945 [5] Case reports also exist of fistulation
following aortic aneurysm surgery and even after
laparo-scopic appendectomy [6] Post-traumatic AVFs may
pre-sent many years after the initial injury, some reporting a
traumatic history as distant as 30 to 52 years previously
[7] In such cases, the remote injury in combination
with the diverse and subtle modes of presentation can
result in delayed or overlooked diagnosis of the fistula
Typical symptoms include back pain (70%) and
progres-sive sequelae from high output CCF (such as
orthop-noea, edema and fatigue) [4] An abdominal bruit is
commonly demonstrable (80%) Our patient reported
unilateral, progressive leg claudication, confirmed with
unilaterally reduced ABI and toe pressure readings This
reflected a steal phenomenon which was subsequently
fully reversed following exclusion of the AVF To the
best of our knowledge, this interesting phenomenon has
not previously been described
Treatment of iliac AVFs in the open vascular surgical
era was fraught with danger, with reported surgical
mor-tality rates of 9-34% Operative blood loss of six liters
was common [8] Acute presentations with spontaneous
ruptures are thankfully rare (less than 4% of ruptured
aneurysms [9]) but carry a significantly higher mortality
rate
Conclusion
The evolution of endovascular surgery has led to a
para-digm shift in the approach to managing aneurysmal
dis-ease with a concomitant vast reduction in mortality and
morbidity rates The first endovascular exclusion of an
iliocaval fistula appeared in 1995 [10] We add to the
lit-erature this report of a successful endovascular
exclu-sion of a giant, spontaneous, ilio-iliac AVF Our case
demonstrates several aspects of modern day vascular
surgery such as the importance of preoperative imaging
and planning, as well as the emerging role for a hybrid
endovascular and open surgical approach to minimize
operative morbidity as well as optimize long-term
suc-cess for such complex vascular pathology
Consent
Written informed consent was obtained from the patient
for publication of this case report and any
accompany-ing images A copy of the written consent is available
for review by the Editor-in-Chief of this journal
Authors ’ contributions
GOB was the main author, treated our patient, researched the topic and
coordinated the editing of the paper CM & ZM were major contributors to
researching, writing and editing the paper NH, MPC, PM, DM & SON were
all involved in making treatment decisions regarding our patient as well as reading, making editorial suggestions and approving the final manuscript All authors read and approved the final manuscript.
Competing interests The authors declare that they have no competing interests.
Received: 5 January 2011 Accepted: 22 August 2011 Published: 22 August 2011
References
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9 Bertinchant JP, Nigond J, Dauzat M, Ovtchinnikoff S, Noblet D, Arnaud E, Bengler C, Arich C, Lopez FM, Hertault J: Arteriovenous fistula caused by spontaneous rupture of an aortic or iliac aneurysm in the iliocaval venous system Arch Mal Coeur Vaiss 1992, 85(1):91-94.
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doi:10.1186/1752-1947-5-401 Cite this article as: O’Brien et al.: Hybrid management of a spontaneous ilio-iliac arteriovenous fistula: a case report Journal of Medical Case Reports 2011 5:401.
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